Manager – Utilization Review Position Available In East Baton Rouge, Louisiana

Manager – Utilization Review Baton Rouge General – 3.7

Baton Rouge, LA Job Details Full-time Estimated:

$73.1K – $91.9K a year 3 hours ago Qualifications Nursing Medicare Utilization review RN License Research Supervising experience Project management Bachelor’s degree Contracts Computer skills Senior level Communication skills Full Job Description

JOB PURPOSE OR MISSION

Under the supervision of the Director of Care Management, the Manager of Utilization Review (UR) will provide clinically oriented management of the daily operations for the Utilization Review Team. The manager will support the coordination the utilization review process through the progression of care, understanding the department aim of resource utilization and throughput. The manager will lead the UR Team to ensure medical necessity and level of care determinations are a priority to facilitate appropriate reimbursement and facilitate timely transition through the hospital progression of care. Performs all job duties for the age population served, as defined in the department’s scope of service.

ESSENTIAL JOB FUNCTIONS

include, but are not limited to: 1. Daily Operations (Maintains an organized department to ensure efficiency, accuracy of work, and information flow.)

PERFORMANCE STANDARDS

Provide frontline support, supervise the daily activities, and manage UR team to ensure performance and process accountability. Ensure collaboration of health care team members in capacity and resource decisions. Provide orientation and continued education for the UR team. Engage and communicate with team members who are needing additional help and support to effectively manage their role. Ensure that established goals, objectives, and departmental priorities are carried out daily and is consistent with the BRG philosophy. Takes a leadership role in organization/department initiatives to ensure success for patient flow and resource utilization. Review daily productivity and coordinate daily staffing needs for the UR team with regards to market/seasonal changes. Assist the Director of Care Management with employee talent management, performance evaluations, and performance improvement for the UR team. Works in collaboration with the Manager of Care Coordination to problem solve regarding complex patient care and organizational/operational issues. Demonstrate knowledge of current payor contracts, organizational policies/procedures, and regulatory changes by ensuring the high quality and safe standard of care. Review monthly expenses as assigned and assists with determination of expenses (e.g., contracts) in budget preparation. Ensure timely follow-up of incident reporting, including grievances. Participates in employee monthly rounding and preparing stoplight reports. Oversees all Krono’s timekeeping transactions and monthly scheduling for the UR Team. 2. Performance and Process Accountability (Participates in the development of departmental goals and objectives.)

PERFORMANCE STANDARDS

Establish and maintain effective working relationships by collaborating and communicating with members of the interdisciplinary team. Ensure that all policies and procedures are followed. Identify and communicate barriers to patient flow and capacity by reporting avoidable days/progression of care opportunities. Participate in team meetings and provide education and support to the department as it relates to progression and transitions of care. Identify performance improvement indicators and initiates monitoring and process improvement activities to ensure compliance. Collaborate with the quality department on readmission data and use proactive strategies to reduce readmission penalties in the organization, ensuring patient success in the outpatient setting. In collaboration with the Manger of Care Coordination, leads the Complex Outlier Patient Engagement (COPE) meetings by identifying complex stays, recommend proactive resources, and provide open discussions for immediate intervention. Assess and communicate resource information related to post-acute partners, insurance payers, bed capacity, and disasters to the organization and department. Assist in the review of departmental data analysis and compilation as necessary. Consistently monitors compliance with standards of care by observation and written documentation. Develop plans to increase compliance and implement actions to correct deficiencies. 3. Utilization Review (Ensures medical necessity and level of care determinations are a priority and clinical reviews are provided timely and with sound clinical judgement.)

PERFORMANCE STANDARDS

Employs sound professional judgment in evaluating for medical necessity and can identify cases where these are not met. Use appropriate judgement and communication skills to articulate escalation of cases to payers, physician advisors, leadership team, and/or medical team. Appropriately prompts attending physicians for needed documentation and facilitates a good working relationship with the attending. Serves as a resource to physicians and healthcare team members in relation to medical necessity and utilization review. Ensure that utilization review conditions of participation are followed per the CMS guidelines. Compile audit reports from utilization review documentation for performance improvement and education. Carries out job functions associated with UR with staffing needs. Collaborate as needed with the revenue cycle team, including patient financial services. 4. Performs all other duties as assigned.

EXPERIENCE REQUIREMENTS

1-year supervisory experience preferred; 3 years of hospital utilization review experience preferred

EDUCATIONAL REQUIREMENTS

Graduate from an Accredited School of Nursing, bachelor’s degree in nursing preferred. Current Louisiana RN licensure Case Management Certification is preferred

SPECIAL SKILL AND KNOWLEDGE REQUIREMENTS

Expert knowledge of InterQual Criteria and MCG Guidelines Current reimbursement models: Commercial, Managed Care, Medicare, and/or Medicaid. Knowledge of local and national coverage determination Essential leadership, advocacy, communication, education and counseling, and resource research skills Expertise in project management and training Knowledge of CMS Condition of Participation Guidelines Current reimbursement models: Commercial, Managed Care, Medicare, and/or Medicaid Clinical knowledge of evidenced-based clinical practice, clinical trajectories, and recovery patterns Strong analytic, data management, and computer skills Effective verbal and written communication skills Ability to manage multiple priorities Healthcare law and regulations related to acute care and the immediate post-acute continuum